What is the recommended management for a patient with lateral epicondylitis (tennis elbow) who declined an X‑ray and oral NSAIDs?

Recommended Management for Tennis Elbow

Your patient should begin eccentric strengthening exercises combined with continued ice application, and you should offer topical NSAIDs as an alternative to oral NSAIDs, along with education about activity modification and the expected 3-6 month recovery timeline. 1, 2

Core Treatment Components

Activity Modification and Relative Rest

• Instruct the patient to reduce or modify activities that involve repetitive wrist extension against resistance (such as gripping, twisting motions, computer mouse use, or lifting with the palm down), as these movements cause ongoing microtrauma at the lateral epicondyle 3, 1
• Emphasize that relative rest does not mean complete immobilization—activities that don't worsen pain may continue, but those causing pain should be temporarily stopped or modified 1, 2
• Complete immobilization should be avoided as it leads to muscle atrophy and deconditioning 1

Cryotherapy (Ice Application)

• Continue ice application for 10-minute periods through a wet towel, which provides effective short-term pain relief 4, 1
• This can be repeated multiple times daily as needed for symptom control 4

Eccentric Strengthening Exercises (Most Important)

• Eccentric strengthening is the cornerstone of treatment and may reverse degenerative tendon changes 4, 1
• These exercises promote tendon healing, increase strength, and stimulate collagen production with proper fiber alignment 1, 2
• Should be combined with stretching exercises for the wrist extensors 1, 2
• Tensile loading of the tendon through these exercises guides normal collagen alignment 1

Pain Management Alternatives

Since the patient declined oral NSAIDs:

• Offer topical NSAIDs as an alternative, which are effective for pain relief and avoid gastrointestinal side effects of oral formulations 4, 1
• Topical NSAIDs can reduce tendon pain while minimizing systemic risks 1

Counterforce Bracing

• Consider a tennis elbow band (counterforce brace) to reinforce, unload, and protect the tendon during activities 1
• While evidence is limited, clinical experience and patient preference should guide this decision 4

Patient Education Points

Expected Timeline

• Reassure the patient that approximately 80% of cases fully recover within 3-6 months with conservative treatment alone 2
• Most patients experience significant improvement within this timeframe 2

Warning Signs and Aggravating Activities

• Pain typically worsens with activities requiring wrist stabilization in extension while the elbow is straight 3
• Common aggravating movements include shaking hands, opening doors, gripping with simultaneous wrist extension, and computer mouse use 3
• The dominant arm is affected 75% of the time, reflecting the role of repetitive use 3

Movement Modifications

• Modify gripping technique to reduce stress on the lateral epicondyle 3
• Incorporate appropriate warm-up before activities involving repetitive wrist extension 3
• Avoid activities that don't allow proper rest between repetitive movements 3

Regarding the Declined X-ray

• Plain radiographs are recommended by the American College of Radiology to rule out fractures, loose bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, or osteoarthritis 2
• However, radiographs are often normal in lateral epicondylitis 2
• If the clinical diagnosis is clear (lateral elbow pain, tenderness over the lateral epicondyle, pain with resisted wrist extension), and there are no red flags suggesting alternative pathology, imaging is not mandatory for initial conservative management 2, 5

Second-Line Options if Conservative Management Fails

Corticosteroid Injection

• If symptoms persist after 4-8 weeks of appropriate conservative treatment, consider locally injected corticosteroids, which may be more effective than oral NSAIDs for acute-phase pain relief 4, 1, 2
• Critical caveat: Corticosteroids do not alter long-term outcomes and may inhibit healing, reduce tendon tensile strength, and potentially predispose to spontaneous rupture 1, 2
• Use with caution and avoid overreliance on this modality 1, 2

Other Modalities

• Deep transverse friction massage can reduce pain 1, 2
• Extracorporeal shock wave therapy appears safe and effective but is expensive and requires further research 4, 1
• Therapeutic ultrasound has weak evidence for consistent benefit 1

Surgical Referral Criteria

• Surgery should only be considered if pain persists despite 6-12 months of well-managed conservative treatment 1, 2
• Surgery typically involves excision of abnormal tendon tissue and longitudinal tenotomies 1, 2

Common Pitfalls to Avoid

• Do not rely on corticosteroid injections as first-line treatment—they may weaken tendons and increase rupture risk 1, 2
• Avoid complete immobilization—it causes muscle atrophy and worsens outcomes 1, 2
• Do not skip eccentric strengthening exercises—they are the most effective long-term treatment 4, 1